LCD L34538Free — notepush.com

Cardiac Disease / Congestive Heart Failure — Hospice Visit Note Template

CHF charts live or die on specifics: daily weight trend, NYHA class, documented EF, and symptom burden at rest. This template captures every data point the LCD requires and the ones auditors look for first.

LCD L34538 Quick Check

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NYHA Class IV documented (symptoms at rest)

Or treatment-refractory arrhythmia

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EF ≤ 20% documented

From echo — include date

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On optimal medical therapy (diuretics + vasodilators)

Or documented intolerance

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PPS ≤ 70%

Most end-stage CHF: PPS 40–50

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Dependent in ≥ 2 ADLs (documented by name)

Check all boxes before filing.

Visit Information

Date

Visit time / duration

Patient MRN

Benefit period

Vital Signs

BP (sitting)

BP (standing if tolerated)

HR (regular / irregular)

Temp

SpO₂(on RA ___% | on ___ L O₂ ___%)

Weight & Fluid Status (Critical for CHF)

Weight today(lbs — same scale, same conditions?)

Weight last visit (date)(lbs on ___)

Change since last visit(lbs gained / lost)

Dry weight (if established)(lbs)

Deviation from dry weight(lbs above / below)

Daily weight log reviewed(Y / N — trend: ___)

Cardiac Assessment

NYHA Functional Class— Class IV = symptoms at rest — required for LCD

☐ I☐ II☐ III☐ IV

Most recent Ejection Fraction(___% from echo dated ___ — EF ≤ 20% required for LCD (or rest symptoms))

Dyspnea

☐ At rest☐ On minimal exertion☐ On moderate exertion☐ On strenuous exertion only

Orthopnea(Number of pillows / can lie flat: Y / N)

PND (paroxysmal nocturnal dyspnea)(Y / N — frequency)

Rhythm

☐ Regular☐ Irregular☐ A-fib☐ Other: ___

Chest pain / angina(Y / N — describe)

Syncope or near-syncope(Y / N — frequency)

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Free template — 10 sections

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What's in the full template (10 sections):

✓Visit Information

✓Vital Signs

☐Weight & Fluid Status (Critical for CHF)

☐Cardiac Assessment

☐Edema Assessment

☐Medications & Compliance

☐Palliative Performance Scale

☐ADL Status

☐Comfort & Symptom Burden

☐Family / Caregiver & Plan

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